Quick question for my American chums

[Gob]

In work we have a new client who is a persistent and profound self harmer. She cuts herself with razors, mainly on her arms and thighs. Sometimes she needs hospital attention for this, for treatment of the wounds and for stays on the psychiatric ward for, observation and for safety at high risk times.

Would the family be able to get insurance for this girl in the US? Seeing as her wounding is self inflicted and persistent, would she be pricing herself out of the market?

[Crackpot]

It might get caught under a pre-existing condition clause. THough it would seem unlikely that she'd go so long without geting some sort of insurance (if only medicaid) under those circumstances.

THough someone who knows better than me could probably give a better answer.

[Sue U]

It would depend on what state she lived in and what that particular state requires of health insurers -- there is wide variability in what mental health benefits (if any) must be provided under state law, and further variation in what different insurers may offer as optional additional coverages. Here's a pretty good starter overview of what's available where.

[Gob]

Many thanks Sue! It's a complex situation, I'm trying to find out what cover and how private insurers here would deal with it.

[Rick]

Arkansas is a lot more progressive in this area than they were just a few years ago...

[rubato]

Coverage for mental health is almost non-existent. Even if you have "good" employer-paid health care. She would get a few visits with a psychiatrist per year and that's it.

We have the Ron Paul "let 'em die" coverage for mental health.




yrs,
rubato

[dales]

Wrong, as usual.

[BoSoxGal]

Actually, laws enacted under Clinton mandate some mental health coverage - but it is woefully inadequate, to be sure.

Something like 40-50 sessions per year of psychotherapy, coverage of meds, but very limited coverage for inpatient treatment on most plans.

Inadequacy of mental health coverage is one of the reasons Andrea Yates was sent home psychotic and ultimately killed her five kids. That, and her husband's insistence on getting her pregnant again and again.

[dgs49]

I think the question is more about treatment for the specific, self-inflicted injuries rather than the underlying mental health issue.

If a person has medical coverage, there is no provision to deny coverage for a wound or a broken arm, for example, because it is self-inflicted. Such a provision would be fifty pages long and totally unenforceable (the patient will always lie about the cause of the injury).

Do I read you correctly, Gobster?

[Gob]

Both actually as they are part of the same condition, one could be seen as a symptom of the other.

[Rick]

It might get caught under a pre-existing condition clause. THough it would seem unlikely that she'd go so long without geting some sort of insurance (if only medicaid) under those circumstances.

THough someone who knows better than me could probably give a better answer.

This is not very current and I don't actually know it's origins other than the letter head

Under federal law, a group health insurance plan cannot exclude coverage for self-inflicted injuries. An individual health insurance plan can only exclude coverage for self-inflicted injuries if the plan excludes pre-existing conditions and the covered individual had a history of mental illness when enrolling in the plan.

ETA: After further review it appears to be from Connecticut...

[Andrew D]

Coverage for mental health is almost non-existent. Even if you have "good" employer-paid health care. She would get a few visits with a psychiatrist per year and that's it.

I guess that that depends on how one defines "good". If that description is accurate, then my employer-paid health insurance must be "way, way, way more than good".

I can see a psychiatrist for $15.00 per session. I can see a psychiatrist for $15.00 per session as often as necessary. I could see a psychiatrist every week for the entire year, and it would be $15.00 per session.

I can get "mental health intensive outpatient care" (partial day hospitalization) for $0.00. As often as necessary.

I can get inpatient care -- psychiatric or otherwise -- for $100.00. And that's $100.00 per admission, regardless of how long I stay.

I'm admitted to the hospital with what could be an attack of acute pancreatitis or an attack of renal colic or both. They do blood tests for amylase and lipase levels. They do a CT-scan for kidney stones. They give me continuous intravenous hydration and banana bags. They load me up with intravenous painkillers. And when I am discharged -- two, three, four days later; whatever -- they send me home with oral-ingestion painkillers.

The whole thing costs me $100.00.

If they had to do the same sort of thing for psychiatric reasons, which I have at least thus far been spared, I could be there three days or five days or a week, and it would cost me $100.00. And if the following month I had to go back -- complete with tests and medications and all that -- for another three days or five days or a week, that would cost me another $100.00.

And some people still wonder why labor unions are good things ....

[Sue U]

You can always find an insurer to write a policy that covers whatever you need it to cover, the question is at what price. The starting point here is the individual state's mandated benefits law, which establishes the minimum coverages that all health insurers operating in that particular state must provide. Above that, insurers will offer a variety of coverages, "deductibles" and "co-pays," and plan structures (HMO, PPO, POS, indemnity, etc.). Prescription drug benefits may or may not be part of the plan. Some plans, like Andrew's, will provide fairly generous benefits in some areas (but maybe not so much in others); it's all according to how the insurer thinks it can turn a profit on the premiums paid for the mix of benefits offered under any given plan.

Moreover, because health coverage in the US is (stupidly, for stupid historical reasons) overwhelmingly employment-based, many employers provide health coverage through self-funded plans rather than through insurance policies. This means that, essentially, the employer (or, in the case of industry-wide union plans, a group of employers and the union) sets up a fund, generally with contributions from both the employees and the employer, and pays the employees' health claims out of that fund, rather than transferring that risk/responsibility to a commercial insurance company through purchase of a traditional insurance policy. These plans are not regulated by state law and so are not subject to state mandated benefits requirements.

As you can see, it can get pretty complicated over here and there's really very little way to ensure you're actually getting value for your health insurance dollar; further, because health coverage is primarily employment-based, as a practical matter there is usually very little choice in what coverage you get: you're stuck with the plan or plans offered through your employer. I can't imagine why anyone (other than a health insurance company executive) would prefer this confusing, balkanized and inefficient system to a uniform single-payer model, but that's what we've got.

[Long Run]

Re mental health benefits, the Mental Health Parity Act (and similar laws in various states) has made big changes in this area in the last few years. Essentially, an employer plan does not need to offer mental health benefits, but if it does (and the vast majority do), it has to offer the benefits on the same basis as other medical benefits are offered. As a result, most of the previous limits on number of visits and the like have gone away.

[dgs49]

How broadly are you willing to go with the "self inflicted" definition?

I have skin cancer. From spending too much time in the sun with no shirt and no other protection from the sun.

Self-inflicted?

Being fat - a condition that is entirely preventable - can bring a whole cornucopia of related problems including heart disease, hypertension, foot and joint problems, arthritis, diabetes, trouble breathing...

Self-inflicted?

It's no secret how most people contract STD's, including AIDS.

Self-inflicted?

Motorcycle accident? Skydiving accident? Running injuries? Rollerblading injuries?

Medical conditions relating to substance abuse?

If you excluded self-inflicted or self-precipitated diseases, health insurance would be Waaaaaay Cheap!

[dales]

Compares skin cancer with "cutting".

dsg, you are a DOOFUS!

[Rick]

Dave he was pretty specific he said shes cuts herself with razors on the arms and legs (mainly), didn't mention while sunbathing...

[dgs49]

Did you read the first line of my post?

I was not comparing self-inflicted razor cuts with sunbathing.

[Rick]

Again, he was specific, did you read the OP?

[Sue U]

Further to Long Run's post, here is a brief announcement from the U.S. Departments of Labor, Treasury and Health & Human Services concerning recent federal rules for mental health parity in group health plans.